CDMP-5000 Application Package for Endorsement of Foreign Officer Certificates of Competence
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The Commonwealth of Dominica Office of the Maritime Administrator CDMP-5000 Application Package for Endorsement of Foreign Officer Certificates of Competence 32 Washington St. Fairhaven, MA 02719 USA Tel: 001-508-992-7170 Fax: 001-508-992-7120 [email protected] www.dominica-registry.com THE COMMONWEALTH OF DOMINICA Office of the Maritime Administrator APPLICATION FOR DOMINICA ENDORSEMENT OF FOREIGN OFFICER’S STCW CERTIFICATE OF COMPETENCE, DOMINICA MARITIME LICENSE, AND SEAFARER’S ID BOOK MAKE SURE ALL BOXES ARE COMPLETED. TYPE OR PRINT CLEARLY. PART I. PERSONAL DESCRIPTION AND INFORMATION: 1. Last Name (Family Name) First Name (Given Name) Middle Initial 2. Date of Birth (dd mm yyyy) 3. Place of Birth (City and Country) 4. Permanent address (street, city and country) 5. Address to which certificate is to be mailed (street, city and country) Telephone Email Telephone 6. Name and relationship of person to be notified in emergency 7. Citizenship 7a. Passport Number 8. Height 9. Weight 10. Color of Hair Telephone Email 11. Color of eyes 12. Distinguishing Marks 13. Sex Male Female PART II. REQUESTED LICENSE/CERTIFICATES: Mark all that apply below, by placing an “X” in the proper box. All applicants are required to have a Dominica SID. INITIAL - I am applying for: RENEWAL/UPGRADE: I am applying for: Certificate of Endorsement AND Seafarer’s Identification & Discharge Book Renewal or Upgrade of Certificate of Endorsement and Seafarer’s Identification & Discharge Book Please choose grade/level of certificate desired: Deck Officers Engineering Officers Grade < 500 GT 500<>3000 > 3000 GT Grade < 750kW 750 <> 3000 kW > 3000 kW Master II/3.5 II/2.3 II/2.1 Ch. Engineer N/A III/3.1 III/2.1 Chief Mate N/A II/2.3 II/2.1 2nd Engineer N/A III/3.1 III/2.1 OICNW II/3.3 II/1 (>500 GT) OICEW N/A III/1 III/1 OICNW II/3.4 near coastal Electro-Technical Officer III/6 Note Limitations here: Not for Service on Tankers Motor Other (please specify) ______________________________ GMDSS Certificate of Competence Original Replacement Renewal I am applying for a Certificate of Competence for GMDSS/Radio Officer Certificate - Reg. IV/2 Ship Security Officer Certificate of Proficiency Original Replacement I am applying for a Certificate of Proficiency as Ship Security Officer – Reg. VI/5 (required for all Officers on board vessels over 500 gross tons) Special Training Certificate of Proficiency Original Replacement I am applying for a Certificate of Proficiency for Training required to serve in certain functions onboard ships: Choose from the below choices: V/1-1.3 – Oil Tanker Personnel Advanced V/1-1.5 – Chemical Tanker Personnel Advanced V/1-2.3 – Liquefied Gas Tanker Personnel Adv. V/2 – Personnel on Passenger Vessels VI/4 – Medical Care Person in Charge VI/6 – Security Awareness Training/Security Training Examination I hereby apply for examination for a Dominica license. Desired Testing Area: Training Record Book I hereby apply for a Training Record Book for upgrade to capacity: CDMP-5000E Rev04 p. 1 Applicant Name: __________________________ Name of vessel on which now serving (or will join): _______________________ PART III. DESCRIPTION OF HIGHEST GRADE FOREIGN CERTIFICATE OF COMPETENCE NOW HELD: Grade of Certificate of Competence Certificate # Date Issued Date Expires Country of Issue PART IV. SEA SERVICE Submit proof of at least the minimum service required (See Attachment A to this application for specific license requirements) during the last five years or more to establish eligibility for the Certificate of Competence requested. This proof may include copies of your discharge book sea service pages (ensure your Seafarer Book ID# is visible on each page) and/or sea service letters provided by your employer. At minimum, this proof shall include: 1. Propulsion (Steam or Motor) 2. Name of Vessel 3. Deck Officers list Gross Tons/ Engineers list kW Propulsion Power 4. Flag 5. Name of Managing Operator 6. Capacity in which served 7. Period of Service PART V. APPLICANTS FOR RADIO OPERATORS CERTIFICATE PART VI. APPLICANTS FOR STCW CERTIFICATE OF MUST READ AND SIGN THIS OBLIGATION. COMPETENCE/ENDORSEMENT AT THE MANAGEMENT LEVEL MUST SIGN THIS AFFIDAVIT/ACKNOWLEDGMENT. By affirming my signature below, I acknowledge that I am obliged to ensure and These applicants include Master and Chief Mate applicants for the service on board ships of 500 maintain the secrecy of all telecommunications of which I may gain knowledge in the gross tonnage or more, as well as Chief Engineer and Second Engineer applicants for service on course of my services, and that I am likewise obliged not to reveal the existence or board ships powered by main propulsion machinery of 750 kW propulsion power or more. I contents of any correspondence to anyone other than the addressee. My signature hereby understand that I will become familiar with the national maritime legislation of the further acknowledges that, if I should breach these obligations, my Certificate of Commonwealth of Dominica relevant to the functions to be performed by me for which I have Competence issued pursuant to this application may be suspended and/or revoked. applied to be certificated, and that those regulations are available on the Administration’s website: www.dominica-registry.com . Signature Signature Copies of the following identity documents (with name and numbers visible) indicated below are being submitted with this application. Originals are required at time of testing: Seafarer’s Book or Card Passport Foreign Certificate of Competence and Endorsement PART VII. AFFIDAVIT OF APPLICANT APPLICATION CANNOT BE ISSUED UNLESS APPLICANT SIGNS BELOW I hereby affirm that all information provided by me in this application and its supporting documents and proofs are true and correct to the best of my knowledge and belief; further, that no certificate issued to me heretofore by any Government has ever been revoked or suspended; or, if revoked or suspended, a full explanation of the circumstances is attached hereto and made part of this application. Date of Application Signature of Applicant ____________________________ _________________________________________________ CDMP-5000E Rev04 p. 2 PART VIII. IDENTIFICATION INFORMATION MARINER APPLICANT FULL NAME : DATE OF BIRTH: PASSPORT# Signature: Please use the space below to sign your name clearly, without touching PHOTO any of the box lines. This signature will be transferred to your Seafarer’s ID book. - ORIGINAL COLOR PHOTO - CLEAR RESOLUTION PLEASE STAY WITHIN THE LINES Thumbprint: Please use the spaces below for 2 copies each of your left and right thumbprint. Using a traditional blue or black inkpad, roll your thumb from the outer edge over to the right edge in the inkpad and then in the space below, roll from left to right onto the paper to create a clear imprint (repeat the process of inking and transferring for each imprint). We are asking for multiple imprints, so we may select the clearest one for imprinting on your Seafarer’s ID book. LEFT THUMB RIGHT THUMB Thumbprint 1 Thumbprint 2 Thumbprint 1 Thumbprint 2 EXAMPLES Unacceptable Unacceptable Acceptable CDMP-5000E Rev04 p. 3 PART IX GENERAL INFORMATION AND INSTRUCTIONS 1. READ INSTRUCTIONS CAREFULLY. Enter all required information. Please use computer or print legibly. Failure to properly complete this application or to submit required supporting proofs, etc. will result in rejection of the application or delay its approval. PLEASE DO NOT STAPLE THE APPLICATION OR ITS ATTACHMENTS. 2. WHERE TO APPLY. Applications must be submitted, by mail or in person, to: Dominica Maritime Registry, Inc., 32 Washington Street, Fairhaven, Massachusetts 02719 USA 3. GENERAL INFORMATION (a) This application is subject to the approval of the Maritime Administrator, Commonwealth of Dominica. In the event approval is not granted, all application documents together with the issuance fee (less shipping costs) shall be returned to the applicant at the mailing address indicated. If the application is approved, the issued certificate/identification book will be sent to the mailing address indicated. The ‘certified copy’ of Form CDMP-5000 is to be retained by the seafarer as evidence that the application is being processed. (b) Seafarer’s ID and Discharge Book (SIB): This identification document conforms to the requirements of the International Labor Organization (ILO) Convention No. 185 (Seafarer's Identity Documents Convention, 2003). It is issued to seafarers of Commonwealth of Dominica flag vessels for use when traveling to or from an assigned vessel or pursuant to instructions from the master of such a vessel. Other uses of the book must be in conformity with Commonwealth of Dominica regulations. ILO 185 does not in any way restrict the right of a member nation from preventing any particular individual from entering or remaining in its territory. (c) The SIB and Training Record Books are issued under the authority of Chapter 8 of the International Maritime Act 2000, as amended. The SIB and TRB remain the property of the Maritime Administrator and may be withdrawn at any time. It may not be altered in any way (other than for the purpose of recording sea time or to records completed assessments) nor be allowed to pass into the possession of an unauthorized person. If the TRB becomes filled with entries, requires alteration, becomes damaged, application for a replacement TRB should be made immediately. If the SIB, TRB or Certificate of Competence is stolen, lost, or accidentally destroyed, notification should be given immediately to office of the Maritime Administrator, and an application for a replacement SID/TRB may be made along with an Affidavit of Lost, Stolen or Destroyed Certificate or Document. (Form CDMP-5000 and CDMP-4007) 4. AGE AND CITIZENSHIP REQUIREMENTS. Please refer to Appendix A for age requirements for specific licenses and endorsements. Applicants may be of any nationality and need not be citizens or residents of the Commonwealth of Dominica.